BPAS Taunton Central

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We also looked at systems and processes which kept women safe from harm. Women were fully involved in their treatment pathway.

The service had a proactive, systematic approach to learning. There was an awareness of the areas with the greatest safety risks and staff understood and managed risks. Leaders investigated incidents thoroughly and were open and transparent when things went wrong. The facilities and equipment met the needs of women. Women were protected by a clear approach to safeguarding. Staff received training and regular appraisals to maintain high quality care. Staff managed medicines well and involved women in planning.

The service had made improvements since our last assessment and now used a Termination Early Warning Score (TEWS) tool (a system used to identify deteriorating patients) which included children under the age of 18 years undergoing surgical terminations of pregnancy.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant women were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well. There were up-to-date policies and procedures to support reporting, investigating and learning from incidents. Leaders told us they encouraged staff to report incidents to ensure risks could be identified and actions taken. Staff said they understood the types of incidents which needed to be reported and how to use the provider’s electronic reporting system.

Staff understood the importance of professional duty of candour. They were open and transparent and gave women and families a full explanation when things went wrong.

The service worked with other BPAS locations to share incidents and promote patient safety. Incidents were reviewed at twice weekly divisional meetings. Learning outcomes were identified and escalated as required. Staff told us the service was responsive to concerns. Learning was shared with staff during daily meetings and displayed on staff noticeboards. Staff were debriefed and received support following any serious incidents.

Women we spoke with during the assessment did not have any safety concerns.

The service worked with women and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when women needed to speak to different members of the team.

Safety and continuity of care was a priority throughout women’s care journey. Staff worked with partner organisations to ensure women remained safe. There were clear referral pathways with external agencies including the local early pregnancy assessment unit, domestic abuse support and counselling services.

Women were fully briefed at admission for treatment regarding post operative care and discharge arrangements. All women having conscious sedation would be asked whether they would have someone with them for 24 hours post treatment to support recovery. Women could choose to receive a discharge letter. Women could also agree to have a copy of the letter sent to their GP. The discharge letter could be used to advise health providers what medication had been taken or in the event of a medical emergency.

Women were given options regarding their fetal remains. They could consent to the service providing sensitive disposal or some women took them away if they wished. We observed remains stored in appropriate refrigeration, clearly labelled with tracing numbers and logged electronically.

Women had access to the provider’s aftercare team who could be contacted 24 hours a day, 7 days a week. All women were advised to contact the team if they had any concerns.

The service worked with women and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving women’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had up-to-date policies and processes to protect adults and children from abuse and unsafe treatment and staff knew how to identify those at risk. This included working in partnership with other services. Referrals to the local authority were documented. There were systems and processes in place to monitor safeguarding.

Staff received training regarding female genital mutilation (FGM) and understood their reporting responsibilities if they suspected abuse.

Staff received adult and child safeguarding training appropriate to their roles. Non-clinical staff received level 1 and 2, and nurse midwife practitioners and surgeons received level 1, 2 and 3 training. The team had an allocated safeguarding specialist midwife, who was level 4 trained. There was a strong understanding of safeguarding and how to take appropriate action. Staff knew how to access safeguarding policies and raise concerns and knew who the safeguarding leads were, how to contact them and seek support and advice.

Staff completed mandatory training and understood the Mental Capacity Act (MCA) to protect the interests of vulnerable persons who lacked capacity to keep them safe from harm.

There was a process for managers to follow to check all staff had an up-to-date enhanced Disclosure and Barring Service (DBS) check and, where applicable, had kept their nursing or midwifery registration up to date.

A poster in the waiting area highlighted availability of the BPAS chaperone service, advising how to request a chaperone. Chaperones were used to help women feel safe and comfortable during medical examinations and could provide emotional support and reassurance.

Staff asked all women if they felt safe with the person they had an intimate relationship with and if they were being asked to do things they were unhappy with as part of the safeguarding assessment.

The service followed Fraser guidelines when determining a child’s capacity to consent to medical treatment and decisions relating to sexual health.

Women using the service told us they felt supported and safe.

The service worked with women to understand and manage risks by thinking holistically. Staff provided care to meet women’s needs that was safe, supportive and enabled women to do the things that mattered to them.

Initial consultations and pre-operative assessments were carried out in line with national guidance and all forms were completed and documented electronically. To meet legislation requirements, a HSA1 (Health Service Administration) form was completed by 2 doctors, before medication to terminate a pregnancy was dispensed to women or surgical treatment carried out. Records showed HSA1 forms were completed to demonstrate legislation was met. Staff also completed HSA4 forms to notify the government about each termination which took place. Completion of both forms was monitored by the service weekly.

Non-clinical staff were trained in basic life support and all clinical staff were fully trained in immediate life support, including resuscitation.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. Staff used a modified Termination Early Warning Score (TEWS) (a system used to identify deteriorating patients) which included blood loss and was appropriate for both women and girls under 18 years of age. The TEWS scoring tool was used alongside nurses and midwifes’ professional judgement. Records showed staff had identified deteriorating patients and treated them accordingly.

There were processes to respond to medical emergencies. There was a formal process to transfer women to hospital which was jointly monitored and reviewed by the service and hospital.

Staff used a modified surgical safety checklist based on the World Health Organization (WHO) 5 steps to safer surgery checklist (a tool designed to improve the safety of surgical procedures) when undertaking all surgical terminations. We observed surgical staff completing the checklist at the time of surgery. The service audited completion of the checklist.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service carried out environmental risk assessments and followed controlled measures to minimise risks. There was designated space for waiting, consultation, scanning, treatment and recovery. Staff told us premises and equipment were suitable for providing safe care and treatment and there was enough well-maintained equipment. Staff knew how to report faulty equipment.

We observed equipment was well-maintained, and regular equipment services were recorded including medical gas bottles. Equipment trolleys were fully stocked, and products were well within expiry dates.

The service had suitable equipment to respond to a deteriorating woman. The resus trolley contained a dedicated box containing the antidotes to the conscious sedation. This equipped all staff with the correct antidote treatment in case of an emergency situation. We observed the trolley and box were regularly checked to ensure they were fully stocked and items were within expiry dates.

We observed records of regular fire alarm testing, training and evacuation drills. A member of staff was a designated fire marshall.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care which met women’s individual needs.

At the time of our assessment the clinic was fully staffed. Leaders calculated the number and grade of nurses and healthcare assistants required, and planned rotas in advance to identify staffing shortages and arrange cover from other locations. Staff were experienced and qualified and had the right skills and knowledge to meet women’s needs.

No bank or agency staff were employed. All staff working in the service were familiar with policies and procedures therefore staff across the south-west area were available to work at any location as required.

Managers provided new staff with appropriate induction and ongoing supervision (meetings to discuss care management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance.

A team of doctors was employed by the organisation and could be contacted at all times through an online messaging platform.

Staff used an online system to complete mandatory training. Staff received alerts when training needed to be completed or new modules were available. Managers monitored compliance with training and ensured staff were allocated time to complete any training.

The service carried out regular checks on nursing staff’s professional registration.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

All patient areas and clinic rooms appeared visibly clean and tidy. They were well equipped, furnished and maintained. We observed the treatment room and equipment was cleaned between appointments. Handwashing guidance posters were displayed and clinical areas had suitable sinks to maintain hand hygiene and hand gel was provided.

We viewed monthly cleanliness and Personal Protective Equipment (PPE) audits. We observed PPE was available, staff wore appropriate PPE and were ‘bare below the elbow’ in line with guidance.

We saw evidence of good waste management processes. Re-usable medical devices were appropriately packaged. After using instruments, stickers were attached to the operation notes for tracking. There were disposable and single use instruments available, and these were disposed of in the clinical waste as required.

Clinical and domestic waste bins were labelled, locked and emptied regularly. Sharps bins were stored safely. Quality assurance audits were completed every 6 months by the quality matron including checks on signage, health and safety, sharps bins and medicines.

Records showed staff completed infection prevention and control (IPC) training.

Between July 2024 and July 2025 there were no cases of healthcare acquired infections. Monthly IPC audits were conducted to ensure compliance with national standards. The service’s overall score for IPC specialist practitioner annual audits 2024 was 96%. Hand hygiene and uniforms audits were carried out monthly and showed staff were compliant. Good practice was shared between locations. Recently plastic trays replaced pulp trays.

There were processes to regularly clean the environment and equipment. During the assessment we observed staff completing cleaning between clinic appointments to reduce the spread of infection. Staff knew who to contact to find more advice. The service subcontracted general cleaning which was monitored by audits.

There was a policy based on the Human Tissue Authority (HTA) guidelines and staff followed this for the management of pregnancy remains. We observed that all products were stored, labelled and registered.

Women using the service told us they found the location very clean.

The service made sure that medicines and treatments were safe and met women’s needs, capacities and preferences. They involved women in planning, including when changes happen.

Medicines including controlled drugs and oxygen were stored securely and safely. Medicines were available for use in an emergency.

Staff followed established systems to manage medicines safely with a system for dispensing pre-pack medicines. Women assessed as suitable for an early medical abortion in the clinic were issued with a pack containing medicine from the on-site medicines store. Appropriate medicines related risk assessments were completed, and local and national guidance was followed when prescribing.

The resus trolley included a box containing antibiotics for women should they display signs of sepsis. Therefore, all staff had the correct treatment in case of an emergency situation and antibiotics could be administered quickly while waiting for an emergency ambulance.

Medicine administration records were completed. There were robust processes to ensure women received appropriate information on how to take their medicines as well as verbal counselling.

Staff completed medicines management training and annual assessments were completed to ensure they remained competent. Medicines audits were completed regularly and any actions identified were communicated to staff.

The service had systems to ensure staff knew about safety alerts and incidents. We saw reported incidents were monitored and reviewed, and where required, changes to practice were implemented.